Yield of Practice-Based Depression Screening In VA Primary Care Settings

VA Greater Los Angeles Center of Excellence for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 10/2011; 27(3):331-8. DOI: 10.1007/s11606-011-1904-5
Source: PubMed


Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.
We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.
Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.
Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.
PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.
Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).
Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

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Available from: Barbara F Simon, Oct 03, 2015
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    • "An example is that the twostage screening process consisting of PHQ-2 and PHQ-9 was reported as confusing when administered by ward nurses (Smolderen et al., 2011). The importance of psychologist education is underscored here and by the fact that other barriers to depression screening include a lack of education regarding nondepression psychiatric co-morbidities (e.g., anxiety) and a high false positive rate for depression detection (Yano et al., 2012). Other health-care factors hindering concerted efforts to manage depression have included a lack of clarity over suitable follow-up procedures (Hasnain, Vieweg, Lesnefsky, & Pandurangi, 2011). "
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    ABSTRACT: Depression prevalence is between 15% and 20% in coronary heart disease patients, such as those with angina, or after a myocardial infarction or coronary artery bypass graft surgery. The presence of depression places a coronary heart disease patient at twofold higher risk for further major cardiac events and death, as well as poor quality of life and early exit from the labour force. As a consequence, several learned societies, including the National Heart Foundation of Australia, have published guidelines that recommend questionnaire screening to improve identification and management strategies for depression in coronary heart disease patients. Psychologists in hospitals, community settings, and private practice can have a key role in the realisation of the National Heart Foundation of Australia's aims. We review the recent guidelines and outline implications for psychologists to identify and manage depression in coronary heart disease patients. The evidence reviewed suggests that cognitive-behavioural therapy and problem-solving therapy are frontline non-pharmacological interventions for depression in CHD patients.
    Australian Psychologist 11/2014; 49(6):337–344. DOI:10.1111/ap.12075 · 0.61 Impact Factor
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    • "However, epidemiological studies have reported varying results. In a study of routine primary care involving more than 10,000 patients in the United States, a yield of 20.1% positive screens was reported using the PHQ-2 score [35]; while a similar study of 532 patients in Norfolk reported a much smaller yield of 2.3% using the two stem questions (‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’ and ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’) as a screening tool [36]. "
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    ABSTRACT: Depression screening in chronic disease is advocated but its impact on routine practice is uncertain. We examine the effects of a programme of incentivised depression screening in chronic disease within a UK primary care setting. Cross sectional analysis of anonymised, routinely collected data (2008-9) from family practices in Scotland serving a population of circa 1.8 million. Primary care registered patients with at least one of three chronic diseases, coronary heart disease, diabetes and stroke, underwent incentivised depression screening using the Hospital Anxiety and Depression Score (HADS). 125143 patients were identified with at least one chronic disease. 10670 (8.5%) were under treatment for depression and exempt from screening. Of remaining, HADS were recorded for 35537 (31.1%) patients. 7080 (19.9% of screened) had raised HADS (≥8); majority had indications of mild depression with HADS between 8 and 10. Over 6 months, 572 (8%) of those with raised HADS (≥8) were initiated on antidepressants, while 696 (2.4%) patients with normal HADS (<8) were also initiated on antidepressants (relative risk of antidepressant initiation with raised HADS 3.3 (CI 2.97-3.67), p value <0.0001). Of those with multimorbidity who were screened, 24.3% had raised HADS (≥8). A raised HADS was more likely in females, socioeconomically deprived, multimorbid or younger (18-44) individuals. Females and 45-64 years old were more likely to receive antidepressants. retrospective study of routinely collected data. Despite incentivisation, only a minority of patients underwent depression screening, suggesting that systematic depression screening in chronic disease can be difficult to achieve in routine practice. Targeting those at greatest risk such as the multimorbid or using simpler screening methods may be more effective. Raised HADS was associated with higher number of new antidepressant prescriptions which has significant resource implications. The clinical benefits of such screening remain uncertain and merits investigation.
    PLoS ONE 09/2013; 8(9):e74610. DOI:10.1371/journal.pone.0074610 · 3.23 Impact Factor
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    • "Repeated deployments (with short dwell time between them), combat exposure, and dealing with death, injuries, and chronic pain as well as separation from loved ones have been associated with ever increasing rates of posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and depression (Bass & Golding, 2012; Finley, Address correspondence to Peter Vazan, National Development and Research Institutes, 71 West 23rd Street, 8th floor, New York, NY 10010, USA; E-mail: 2011; SAMHSA [Substance Abuse and Mental Health Services Administration], 2008; Wells et al., 2010; Yano et al., 2012). In addition, large numbers of service members engage in heavy drinking, misuse of substances (primarily prescription drugs), smoking of tobacco, and in many cases, develop substance use disorders (SUDs). "
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    ABSTRACT: Estimates of substance use and other mental health disorders of veterans (N = 269) who returned to predominantly low-income minority New York City neighborhoods between 2009 and 2012 are presented. Although prevalences of posttraumatic stress disorder, traumatic brain injury, and depression clustered around 20%, the estimated prevalence rates of alcohol use disorder, drug use disorder, and substance use disorder were 28%, 18%, and 32%, respectively. Only about 40% of veterans with any diagnosed disorder received some form of treatment. For alcohol use disorder, the estimate of unmet treatment need was 84%, which is particularly worrisome given that excessive alcohol use was the greatest substance use problem.
    Substance Use &amp Misuse 07/2013; 48(10):880-93. DOI:10.3109/10826084.2013.796989 · 1.23 Impact Factor
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